Select the action the nurse should take first when a client becomes short of breath, pale, and diaphoretic and complains of localized chest pain after a new bottle of TPN has been hung.
A)Bring the code cart into the room and prepare for cardiac pulmonary resuscitation.
B)Place the bed in Trendelenburg's position and turn the client on the left side.
C)Keep the head and body flat and elevate the legs.
D)Notify the physician that the client is having a myocardial infarction.

Question

Quizplus · Accepted Answer

Placing the bed in Trendelenburg's position and turning the client on the left side is the first action the nurse should take in this scenario. This position helps to increase venous return to the heart, which can be beneficial in cases of air embolism, a potential complication of TPN administration. The symptoms described are consistent with an air embolism, which can occur when a new bottle of TPN is hung and air enters the circulation. This position helps to trap air in the right atrium, preventing it from entering the pulmonary circulation.

Select the Action the Nurse Should Take First When a Client